Michielin O, van Akkooi ACJ, Ascierto PA, et al; ESMO Guidelines Committee. Cutaneous melanoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2019;30:1884-1901.
Axelrod ML, Johnson DB, Balko JM. Emerging biomarkers for cancer immunotherapy in melanoma. Semin Cancer Biol. 2018;52:207-215.
Henderson MA, Burmeister BH, Ainslie J, et al. Adjuvant lymph-node field radiotherapy versus observation only in patients with melanoma at high risk of further lymph-node field relapse after lymphadenectomy (ANZMTG 01.02/TROG 02.01): 6-year follow-up of a phase 3, randomised controlled trial. Lancet Oncol. 2015;16:1049-1060.
Eggermont AMM, Chiarion-Sileni V, Grob JJ, et al. Adjuvant ipilimumab versus placebo after complete resection of stage III melanoma: long-term follow-up results of the European Organisation for Research and Treatment of Cancer 18071 double-blind phase 3 randomised trial. Eur J Cancer. 2019;119:1-10.
National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Melanoma: Cutaneous. Version 1.2021. Published November 25, 2020. Accessed December 17, 2020. https://www.nccn.org/professionals/physician_gls/pdf/cutaneous_melanoma.pdf
Weber J, Mandala M, Del Vecchio M, et al. Adjuvant nivolumab versus ipilimumab in resected stage III or IV melanoma. N Engl J Med. 2017;377:1824-1835.
Weber J, Del Vecchio M, Mandala M, et al. Adjuvant nivolumab (NIVO) vs ipilimumab (IPI) in resected stage III/IV melanoma: 4-y recurrence-free and overall survival (OS) results from CheckMate 238. Ann Oncol. 2020;31(suppl 4): Abstract 1076O.
Ascierto PA, Del Vecchio M, Mandalá M, et al. Adjuvant nivolumab versus ipilimumab in resected stage IIIB-C and stage IV melanoma (CheckMate 238): 4-year results from a multicentre, double-blind, randomised, controlled, phase 3 trial. Lancet Oncol. 2020;21:1465-1477.
Eggermont AMM, Blank CU, Mandala M, et al. Adjuvant pembrolizumab versus placebo in resected stage III melanoma. N Engl J Med. 2018;378:1789-1801.
Eggermont AMM, Blank CU, Mandala M, et al. Longer follow-up confirms recurrence-free survival benefit of adjuvant pembrolizumab in high-risk stage III melanoma: updated results from the EORTC 1325-MG/KEYNOTE-054 trial. J Clin Oncol. 2020;38:3925-3936.
Eggermont AM, Blank CU, Mandala M, et al. Pembrolizumab versus placebo after complete resection of high-risk stage III melanoma: final results regarding distant metastasis-free survival from the EORTC 1325-MG/Keynote 054 double-blinded phase 3 trial. Ann Oncol. 2020;31(suppl 4): Abstract LBA46.
LeBlanc TW, Baile WF, Eggly S, et al. Review of the patient-centered communication landscape in multiple myeloma and other hematologic malignancies. Patient Educ Couns. 2019;102:1602-1612.
Haanen JBAG, Carbonnel F, Robert C, et al. Management of toxicities from immunotherapy: ESMO clinical practice guidelines. Ann Oncol. 2017;28(suppl 4):iv119-iv142.
Brahmer JR, Lacchetti C, Schneider BJ, et al. Management of immune-related adverse events in patients treated with immune checkpoint inhibitor therapy: American Society of Clinical Oncology clinical practice guideline. J Clin Oncol. 2018;36:1714-1768.
KEYTRUDA® (pembrolizumab) [prescribing information]. Merck & Co., Inc.; Approved 2019. Revised January 2020.
Puzanov I, Diab A, Abdallah K, et al. Managing toxicities associated with immune checkpoint inhibitors: consensus recommendations from the Society for Immunotherapy of Cancer (SITC) Toxicity Working Group. J ImmunoTher Cancer. 2017;5:95.
Robert C, Schachter J, Long GV, et al. Pembrolizumab versus ipilimumab in advanced melanoma. N Engl J Med. 2015;372:2521-2532.
Schachter J, Ribas A, Long GV, et al. Pembrolizumab versus ipilimumab for advanced melanoma: final overall survival results of a multicentre, randomised, open-label phase 3 study (KEYNOTE-006). Lancet. 2017;390:1853-1862.
Robert C, Ribas A, Schachter J, et al. Pembrolizumab versus ipilimumab in advanced melanoma (KEYNOTE-006): post-hoc 5-year results from an open-label, multicentre, randomised, controlled, phase 3 study. Lancet Oncol. 2019;20:1239-1251.
Robert C, Long GV, Brady B, et al. Nivolumab in previously untreated melanoma without BRAF mutation. N Engl J Med. 2015;372:320-330.
Ascierto PA, Long GV, Robert C, et al. Survival outcomes in patients with previously untreated BRAF wild-type advanced melanoma treated with nivolumab therapy: three-year follow-up of a randomized phase 3 trial. JAMA Oncol. 2019;5:187-194.
Larkin J, Chiarion-Sileni V, Gonzalez R, et al. Combined nivolumab and ipilimumab or monotherapy in untreated melanoma. N Engl J Med. 2015;373:23-34.
Larkin J, Chiarion-Sileni V, Gonzalez R, et al. Five-year survival with combined nivolumab and ipilimumab in advanced melanoma. N Engl J Med. 2019;381:1535-1546.
Robert C, Grob JJ, Stroyakovskiy D, et al. Five-year outcomes with dabrafenib plus trametinib in metastatic melanoma. N Engl J Med. 2019;381:626-636.
Ascierto PA, McArthur GA, Dréno B, et al. Cobimetinib combined with vemurafenib in advanced BRAF(V600)-mutant melanoma (coBRIM): updated efficacy results from a randomised, double-blind, phase 3 trial. Lancet Oncol. 2016;17:1248-1260.
Ascierto PA, Dummer R, Gogas HJ, et al. Update on tolerability and overall survival in COLUMBUS: landmark analysis of a randomised phase 3 trial of encorafenib plus binimetinib vs vemurafenib or encorafenib in patients with BRAF V600-mutant melanoma. Eur J Cancer. 2020;126:33-44.
Ascierto PA, Ferrucci PF, Fisher R, et al. Dabrafenib, trametinib and pembrolizumab or placebo in BRAF-mutant melanoma. Nat Med. 2019;25:941-946.
Sullivan RJ, Hamid O, Gonzalez R, et al. Atezolizumab plus cobimetinib and vemurafenib in BRAF-mutated melanoma patients. Nat Med. 2019;25:929-935.
Wolchok JD, Chiarion-Sileni V, Gonzalez R, et al. Overall survival with combined nivolumab and ipilimumab in advanced melanoma. N Engl J Med. 2017;377:1345-1356.
OPDIVO® (nivolumab) [prescribing information]. Bristol-Myers Squibb Company; Approved 2014. Revised November 2020.
YERVOY® (ipilimumab) [prescribing information]. Bristol-Myers Squibb Company; Approved 2011. Revised November 2020.
Lee JH, Long GV, Menzies AM, et al. Association between circulating tumor DNA and pseudoprogression in patients with metastatic melanoma treated with anti-programmed cell death 1 antibodies. JAMA Oncol. 2018;4:717-721.
Jansen YJL, Rozeman EA, Mason R, et al. Discontinuation of anti-PD-1 antibody therapy in the absence of disease progression or treatment limiting toxicity: clinical outcomes in advanced melanoma. Ann Oncol. 2019;30:1154-1161.

As an organization accredited by the ACCME, Medscape, LLC requires everyone who is in a position to control the content of an education activity to disclose all relevant financial relationships with any commercial interest. The ACCME defines "relevant financial relationships" as financial relationships in any amount, occurring within the past 12 months, including financial relationships of a spouse or life partner, that could create a conflict of interest.

Medscape, LLC encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content.

Faculty

Caroline Robert, MD, PhD

Head of the Dermatology Unit
Gustave Roussy Cancer Center
Villejuif, France

Disclosures

Disclosure: Caroline Robert, MD, PhD, has disclosed the following relevant financial relationships:
Served as an advisor or consultant for: Amgen; Biothera; CureVac; Bristol Myers Squibb; Merck Sharpe & Dohme; Novartis; Pierre Fabre; Roche; Sanofi

Editors

Charlotte Warren

Senior Medical Education Director, Medscape, LLC

Disclosures

Disclosure: Charlotte Warren has disclosed no relevant financial relationships.

Tristin Abair, PhD

Senior Medical Writer, Medscape, LLC

Disclosures

Disclosure: Tristin Abair, PhD, has disclosed no relevant financial relationships.

CME Reviewer

Stephanie Corder, ND, RN, CHCP

Associate Director, Accreditation and Compliance, Medscape, LLC

Disclosures

Disclosure: Stephanie Corder, ND, RN, CHCP, has disclosed no relevant financial relationships.

Medscape, LLC staff have disclosed that they have no relevant financial relationships.

Peer Reviewer

This activity has been peer reviewed and the reviewer has disclosed no relevant financial relationships.

CME / ABIM MOC

Clinical Decision Making in Melanoma: What Is Best Practice?

Authors: Caroline Robert, MD, PhD
CME / ABIM MOC Released: 2/8/2021
THIS ACTIVITY HAS EXPIRED FOR CREDIT
Valid for credit through: 2/8/2022, 11:59 PM EST

Start Activity

Target Audience and Goal Statement

This activity is intended for hematology/oncology specialists, dermatologists, and pathologists.

The goal of this activity is to improve competence of physicians in the diagnosis and management of patients with melanoma who would benefit from treatment with immune checkpoint inhibitors (ICIs) both in the adjuvant and in the metastatic setting.

Upon completion of this activity, participants will:

Have increased knowledge regarding the
- Use of biomarker testing in patients with melanoma to help guide treatment selection
Have greater competence related to
- Identifying appropriate use of ICIs in patients with stage III or metastatic melanoma
Demonstrate greater confidence in their ability to
- Identify immune-related adverse events in patients with melanoma both during and after treatment with an ICI

Disclosures

Faculty

Caroline Robert, MD, PhD

Head of the Dermatology Unit
Gustave Roussy Cancer Center
Villejuif, France

Disclosures

Disclosure: Caroline Robert, MD, PhD, has disclosed the following relevant financial relationships:
Served as an advisor or consultant for: Amgen; Biothera; CureVac; Bristol Myers Squibb; Merck Sharpe & Dohme; Novartis; Pierre Fabre; Roche; Sanofi

Editors

Charlotte Warren

Senior Medical Education Director, Medscape, LLC

Disclosures

Disclosure: Charlotte Warren has disclosed no relevant financial relationships.

Tristin Abair, PhD

Senior Medical Writer, Medscape, LLC

Disclosures

Disclosure: Tristin Abair, PhD, has disclosed no relevant financial relationships.

CME Reviewer

Stephanie Corder, ND, RN, CHCP

Associate Director, Accreditation and Compliance, Medscape, LLC

Disclosures

Disclosure: Stephanie Corder, ND, RN, CHCP, has disclosed no relevant financial relationships.

Medscape, LLC staff have disclosed that they have no relevant financial relationships.

Peer Reviewer

This activity has been peer reviewed and the reviewer has disclosed no relevant financial relationships.

Accreditation Statements

In support of improving patient care, Medscape LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

For Physicians

Medscape, LLC designates this enduring material for a maximum of 1.0 AMA PRA Category 1 Credit(s)™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 1.0 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit. Aggregate participant data will be shared with commercial supporters of this activity.

Contact This Provider

For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above. For technical assistance, contact [email protected]

Instructions for Participation and Credit

There are no fees for participating in or receiving credit for this online educational activity. For information on applicability and acceptance of continuing education credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on the title page. To receive AMA PRA Category 1 Credit™, you must receive a minimum score of 70% on the post-test.

Follow these steps to earn CME/CE credit*:

Read about the target audience, learning objectives, and author disclosures.
Study the educational content online or print it out.
Online, choose the best answer to each test question. To receive a certificate, you must receive a passing score as designated at the top of the test. We encourage you to complete the Activity Evaluation to provide feedback for future programming.

You may now view or print the certificate from your CME/CE Tracker. You may print the certificate, but you cannot alter it. Credits will be tallied in your CME/CE Tracker and archived for 6 years; at any point within this time period, you can print out the tally as well as the certificates from the CME/CE Tracker.

*The credit that you receive is based on your user profile.

processing....

The following cases are modeled on the interactive grand rounds approach. The questions within the activity are designed to test your current knowledge. After each question, you will be able to see whether you answered correctly and read evidence-based information that supports the most appropriate answer choice. The questions are designed to challenge you; you will not be penalized for answering the questions incorrectly. At the end of the activity, there will be a short post-test assessment based on the material presented.

CASE 1: PATIENT HISTORY AND PRESENTATION

Charles is a 55-year-old married football coach who initially presented with a pigmented skin lesion on his right forearm. Biopsy showed an ulcerated, 3.5-mm thick nodular melanoma, which was removed via wide excision with 2.5-cm negative surgical margins. A sentinel lymph node biopsy (SLNB) performed at the time of surgery showed no metastatic disease in the 2 sentinel nodes examined.

Charles is monitored every 6 months and now, 3 years after his initial diagnosis, has a palpable axillary node under his right arm. He undergoes a complete evaluation and is otherwise healthy, with no significant comorbidities. Charles's initial workup is summarized in Table 1. Chest/abdominal/pelvic computed tomography (CT) with contrast and brain magnetic resonance imaging (MRI) with contrast are both negative for metastatic disease. A complete axillary dissection is performed, which identifies 1 positive lymph node out of 14 total nodes examined. The positive node has 10 mm of melanoma involvement.

Table 1. Summary of Charles's Initial Workup

Demographics	55 years old, male Height: 1.8 meters; Weight: 75 kg; BMI: 23.1
Personal and family medical history	Nonsmoker; no significant comorbidities No prior surgeries Current medications include only supplemental vitamins No family history of cancer
Physical exam	Heart rate 70 bpm, BP 115/82 1 palpable node in right axilla, no skin changes in area of initial lesion on forearm ECOG PS 0
Imaging and nodal evaluation	CT with contrast: negative for systemic metastases Contrast-enhanced brain MRI: negative Completion axillary dissection: 1 of 14 nodes positive for metastatic disease (10 mm tumor involvement)

BMI = body mass index; BP = blood pressure; ECOG = Eastern Cooperative Oncology Group; PS = performance status.

Since molecular testing was not performed on the initial primary tumor, you order biomarker testing of the positive lymph node.

Page 1 of 14

CME / ABIM MOC Information

Print
Like Tweet

Disclaimer

The educational activity presented above may involve simulated, case-based scenarios. The patients depicted in these scenarios are fictitious and no association with any actual patient, whether living or deceased, is intended or should be inferred. The material presented here does not necessarily reflect the views of Medscape, LLC, or any individuals or commercial entities that support companies that support educational programming on medscape.org. These materials may include discussion of therapeutic products that have not been approved by the US Food and Drug Administration, off-label uses of approved products, or data that were presented in abstract form. These data should be considered preliminary until published in a peer-reviewed journal. Readers should verify all information and data before treating patients or employing any therapies described in this or any educational activity. A qualified healthcare professional should be consulted before using any therapeutic product discussed herein.

References

Faculty and Disclosures

Faculty

Caroline Robert, MD, PhD

Editors

Charlotte Warren

Tristin Abair, PhD

CME Reviewer

Stephanie Corder, ND, RN, CHCP

Peer Reviewer

CME / ABIM MOC

Clinical Decision Making in Melanoma: What Is Best Practice?

Target Audience and Goal Statement

Disclosures

Faculty

Caroline Robert, MD, PhD

Editors

Charlotte Warren

Tristin Abair, PhD

CME Reviewer

Stephanie Corder, ND, RN, CHCP

Peer Reviewer

Accreditation Statements

For Physicians

Instructions for Participation and Credit

Clinical Decision Making in Melanoma: What Is Best Practice?

CASE 1: PATIENT HISTORY AND PRESENTATION

Table 1. Summary of Charles's Initial Workup